A survey of access to trial of labor in California hospitals in 2012

Abstract

BackgroundIn 2010, the NIH and ACOG recommended increasing women’s access to trial of labor after cesarean (TOLAC). This study explored access to TOLAC in California, change in access since 2007 and 2010, and characteristics of TOLAC and non-TOLAC hospitals.MethodsBetween November 2011 and June 2012, charge nurses at all civilian California birth hospitals were surveyed about hospitals’ TOLAC availability and requirements for providers. VBAC rates were obtained from the California Office of Statewide Health Planning and Development (OSHPD). Distance between hospitals was calculated using OSHPD geocoding.ResultsAll 243 birth hospitals that were contacted participated. In 2010, among the 56% TOLAC hospitals, the median VBAC rate among TOLAC hospitals was 10.8% (range 0-37.3%). The most cited reason for low VBAC rates was physician unwillingness to perform them, especially due to the requirement to be continually present during labor. TOLAC hospitals were more likely to be larger hospitals in urban communities with obstetrical residency training. However, there were six (11.3%) residency programs in non-TOLAC hospitals and 5 (13.5%) rural hospitals offering TOLAC. The majority of TOLAC hospitals had 24/7 anesthesia coverage and required the obstetrician to be continually present if a TOLAC patient was admitted; 17 (12.2%) allowed personnel to be 15-30 minutes away. TOLAC eligibility criteria included one prior cesarean (32.4%), spontaneous labor (52.5%), continuous fetal monitoring and intravenous access (99.3%), and epidural analgesia (19.4%). The mean distance from a non-TOLAC to a TOLAC hospital was 37 mi. with 25% of non-TOLAC hospitals more than 51 mi. from the closest TOLAC hospital.In 2012, 139 hospitals (57.2%) offered TOLAC, 16.6% fewer than in 2007. Since 2010, five hospitals started and four stopped offering TOLAC, a net gain of one hospital offering TOLAC with three more considering it. Only two hospitals cited change in ACOG guidelines as a reason for the change.ConclusionsDespite the 2010 NIH and ACOG recommendations encouraging greater access to TOLAC, 44% of California hospitals do not allow TOLAC. Of the 56% allowing TOLAC, 10.8% report fewer than 3% VBAC births. Thus, national recommendations encouraging greater access to TOLAC had a minor effect in California.

Association Between Vaginal Birth After Cesarean Delivery and Primary Cesarean Delivery Rates

“…8,9 Indeed, we found some small, rural hospitals to be among the institutions with the highest VBAC rates, confirming prior studies that there is not one single model of VBAC provision. 21,22 Perhaps these “immediately available” emergency cesarean delivery services (however this standard is interpreted) enable health care providers to avoid primary cesarean deliveries for labor dystocia or questionable fetal heart rate tracings, two potentially modifiable indications whose management has been identified as a potential cause of the current high primary cesarean delivery rate.…”

“…19 Both the National Institutes of Health Consensus Conference on VBAC and the College’s Practice Bulletin of 2010 indicate that maternal preference should be the primary determination of whether VBAC is attempted, but this cannot be practically implemented if almost half of California hospitals do not offer that option. 8,9,20 …”

“…Although the American College of Obstetricians and Gynecologists (the College) reaffirmed in 2010 that the opportunity to undergo TOLAC should be made available to most women with one prior cesarean delivery, 8 it has been recently reported that this opportunity is not available to women in 43% of California hospitals and 59% of New Mexico counties. 9,10 Even when hospitals do not ban the procedure, the number of obstetricians who will offer their patients TOLAC is declining and was estimated at only 52% among private obstetricians in Texas in 2010. 11 Some of the causes for this diminished access include uncertainty about whether appropriate emergency care can be offered, concern about the safety of VBAC (primarily focused on the consequences of uterine rupture), and increasing influence of medicolegal liability concerns.…”

Two practice models in one labor and delivery unit: association with cesarean delivery rates

“…While prior studies have documented variation in cesarean rates between U.S. hospitals, 6,9,10 it is difficult to isolate the effect of model of care from other contributory hospital-level factors such as the type of hospital, 11,12 the availability of anesthesia and NICU services, 11 the option to undergo trial of labor after cesarean, 13,14 and, possibly, hospital staff attitudes around cesarean. 5,15 By examining cesarean rates among two different models of care within the same L&D unit, we were able to control for these hospital-level factors.…”

Effect of time of birth on maternal morbidity during childbirth hospitalization in California

“…TOLAC (resulting in either vaginal or cesarean birth) accounted for <1% of births and is not offered in all facilities in California. 34 The California Perinatal Quality Care Collaborative developed and executed the linkage strategy under a grant from the March of Dimes. Stanford University and University of California San Francisco Institutional Review Boards approved the study.…”